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<br />,'~.. ....-...-.. ~"'""<~<:,...;.;.;....,,..,.;->: <br /> <br />'-' ....", <br />Disclosure of Lobbying Activities <br /> <br />Approved by OMB 0348.{)046 <br /> <br />Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 <br />(See reverse side for Instructions and Public Reporting burden statement) <br /> <br />1. Type of Federal Action 2. Status of Federal Action 3. Report Type <br /> oa. contract o a. bid/offer/application o a. initial filing <br /> b. grant b. initial award b. material change <br /> c. cooperative agreement c. post-award For Material Change Only <br /> d. loan year (yyyy) ____ quarter ___ <br /> e. loan guarantee <br /> I. loan insurance date of last report (mm/dd/yyyy)____ <br />4. Name and Address'of Report1ng Entity 5. If Reporting Entity in No.4 1s Subawardee. enter Name and Address <br /> DPrime D Subawardee Tier __, if known: of Prime <br /> Congressional District, if known Congressional District, if known <br />6. Federal Department/Agency 7. Federal Program NameJDescription <br /> -. <br /> CFOA Number, if applicable <br />8. Federal Action Number. if known 9. Award Amount. if known <br /> $ <br />10a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if different from No. 10a.) <br /> (if individual, last name, first name, MI) (last name, first name, Ml) <br /> <br />(attach continuation sheet(s) if necessary) <br /> <br />12. Form of Payment (check alllhat apply) <br /> <br />13. Type of Payment (check all that apply) <br /> <br />o a. retainer <br />o b. one-time fee <br /> <br />D c. commission <br /> <br />o d. contingent fee <br />D e. deferred <br /> <br />o I. other (specify) <br /> <br />14. Brief Description of Services Performed or to be Performed and Date(s) of Service, including officer(s), employee(s), or Member(s) contacted, <br />for Payment Indicated in Item 11 <br /> <br />$ <br /> <br />actual <br /> <br />planned <br /> <br />11. Amount of Payment (check all that apply) <br /> <br />Oa <br />Db <br /> <br />cash <br /> <br />in-kind; specify: nature ____________ <br /> <br />value <br /> <br />(attach continuation sheet(s) If necessary) <br />15. Continuation sheets attached 0 Yes D No <br /> <br />16.lnlormation requested through this form is authorized by Sec.319, <br />Pub. L. 101-121, 103 Stat. 750. as amended by sec. 10; Pub. L. 104- <br />65, Stat. 700 (31 U.S.C. 1352). This disclosure of lobbying activities <br />is a material representation of fact upon which reliance was placed <br />by the above when this transaction was made or entered into. This <br />disclosure is required pursuantto 31 U.S.C. 1352. This information <br />will be reported to the Congress semiannually and will be available <br />for public inspection. Any person who fails to file the required <br />disclosure shall be subject to a civil penally of not less than $10,000 <br />and not more than $100,000 lor each such failure. <br /> <br />Signature <br /> <br />Print Name <br /> <br />Title <br /> <br />Telephone No. <br /> <br />Date (mm/ddlyyyy) <br /> <br />Authorized for Local Reproduction <br />Standard Fonn-LLL (7197) <br /> <br />Federal Use 'Only: <br />